Medicare Advantage Plans (Part C)
Medicare Advantage Plans have become an extremely viable option for people looking to keep their monthly premiums as low as possible, but still have enough coverage and protection from the potentially high out-of-pocket costs one would have with Original Medicare.
Medicare Advantage plans are offered by private insurance companies and they combine Medicare Parts A and B into one convenient plan. Plans must cover all of the medically necessary services that Original Medicare covers. Most plans will include prescription drug coverage and may offer additional benefits not provided by Original Medicare, such as routine dental and vision. One must be enrolled in both Medicare Parts A and B in order to be eligible for a Medicare Advantage plan and they must also live in the plan’s service area. There are many plans with a $0 monthly premium across the nation, particularly in the heavier populated areas. However, plans with a $0 monthly premium are not “free”.
The beneficiary must continue to pay their Part B premium if is not being paid by a third-party entity, such as state Medicaid.
There are many reasons why a person would choose a Medicare Advantage plan. The plans set a limit on what you will have to pay out-of-pocket each year to help protect you from unexpected costs. Most of the medical services already have a set copay amount so that it is easier to predict certain medical expenses, such as hospitalization and diagnostic imaging. The convenience of one complete plan with only one member ID card to demonstrate also simplifies it for the member.
Many of the plans may also have additional benefits that are not covered under Original Medicare, such as:
- Routine Dental (including comprehensive services)
- Routine Vision (including eyewear)
- Hearing (testing and hearing aids)
- Over-The-Counter Health Products
- Personal Emergency Response Systems
- Gym Membership
- Transportation (for Medical appointments and pharmacy)
- Food Benefits Card
- Post-Acute Care meals
Most plans will have a network of doctors within the plan service area that the member will have to use to receive the lowest costs. Some plans may also allow you to see doctors outside of the network, although usually at higher out-of-pocket costs. There are even some plans that may have a nationwide network. All plans will cover emergency and urgent care nationwide, and some even worldwide.
Health Plans of Texas is contracted with all the major carriers that offer Medicare Advantage plans in the West Texas and Southern New Mexico region including, but not limited to:
- Molina Healthcare
You can join, switch, or drop a Medicare health plan or a Medicare Advantage Plan (Part C) with or without drug coverage during these times:
Initial Enrollment Period (IEP) – The three months before the month you become eligible for Medicare, the month you become eligible, and the three months after the month you become are the Initial Enrollment Period. You can join a plan at any time during that period.
Annual Enrollment Period (AEP) – You can join a plan or change to a new plan from October 15 through December 7 each year. Coverage will begin on January 1 as long as you submit your application by December 7.
Medicare Advantage Open Enrollment Period (OEP) – People who are enrolled in a Medicare Advantage plan as of January 1 can make a one-time change during this period which runs form January 1 through March 31. You can change to another Medicare Advantage plan or switch back to Original Medicare with a part D prescription drug plan.
Special Enrollment Period (SEP) – There are various events and situations that may allow a person to join a plan or make a plan change throughout the year. This includes losing employer group coverage, moving from one service area to another and maintaining, gaining or losing low-income subsidy or Medicaid to name a few. The agents at Health Plans of Texas can review your situation to see if you qualify for a special enrollment period and not have to wait for the annual enrollment period.
Types of Medicare Advantage Plans
There are four different types of Medicare Advantage Plans:
- Health Maintenance Organization (HMO) Plans
- Preferred Provider Organization (PPO) Plans
- Special Needs Plans (SNP)
- Private Fee-For-Service (PFFS) Plans
Health Maintenance Organization (HMO) Plans
HMO plans generally have a network of doctors that a member MUST get their care and services from.
Any medical care or services not received from in-network providers will not be covered by the plan with the exception of:
- Emergency Care (ER)
- Out-of-area Urgent Care
- Out-of-area Dialysis centers and services
Though, there are some HMO plans that may allow you to use out-of-network providers for certain services, usually at a higher cost than in-network providers. These types of plans are known as an HMO with a point-of-service (POS) option.
Most HMO plans will require you to choose a primary doctor (PCP) from the list of in-network doctors and require a referral to see a specialist. The member must take care to only seek services within the network to avoid having to pay the full cost of the care. The member must also make sure and follow the plan rules, such as getting prior approval for a certain service when needed.
Certain markets that have both HMO and PPO plans available give people a choice. Some people may not like having to get a referral to see a specialist and will opt for a PPO, however, many people who choose HMOs over PPOs is because HMOs generally have lower copays and richer ancillary benefits than their PPO counterparts.
The experience professionals at Health Plans of Texas can help you review your options to make sure your doctors are in-network and your medications are in the drug formulary in order to find the plan that best fits you.
Preferred Provider Organization (PPO) Plans
PPO plans, like their HMO counterparts, also have a network of doctors, hospitals, and other health care providers. However, the member is not required to only see doctors within the network. The member can see doctors and providers out-of-network, but usually at higher out-of-pocket costs.
One generally does not have to choose a primary doctor (PCP) in a PPO and referrals are not required to see specialists. PPOs may require prior authorization for certain services, though.
A PPO plan is not the same as Original Medicare or a Medicare Supplement Plan (Medi-Gap). However, it is a good option for people who want the flexibility to see doctors in and out of network, but do not want to pay the additional premiums that a Medicare Supplement and a prescription drug plan would incur. PPO plans also offer additional ancillary benefits that Medicare does not cover, such as routine vision and eyewear, dental coverage, and other benefits.
Special Needs Plans (SNP)
Special needs plans are a type of Medicare Advantage plan, which can be an HMO, an HMO-POS, or even a PPO. However, the membership to these plans is limited to people with specific conditions, diseases, or economic situations. If the applicant does not meet any of the requirements for the special needs plan, the person will be unable to enroll.
The different types of special needs plans (SNP) are:
- Dual Special Needs Plans (DSNP) – These types of plans are designed for people who are receiving State assistance for their Medicare cost share, such as Medicaid. Many of these plans have little to no out-of-pocket costs by the member if they maintain their state Medicaid eligibility. These plans also usually extraordinarily rich ancillary benefits, such as high dental benefits, eyewear, hearing aids, food benefits, and high amounts of over-the-counter product benefits.
- Chronic Special Needs Plans (CSNP) – These plans are for people who have specific chronic or disabling conditions (such as diabetes, End-Stage Renal Disease (ESRD), COPD, or chronic heart failure). Enrollment in the plan is contingent on confirmation of the qualifying chronic condition by the doctor that is treating the applicant for the chronic condition.
- Institutional Special Needs Plans (ISNP) – These plans are limited to people who live in certain institutions like a nursing home or an assisted living facility.
Private Fee-for-service (PFFS) Plans
Members of a PFFS plan can go to any Medicare-approved doctor, other health care provider, or hospital that accepts the plan's payment terms and agrees to treat you. However, not all providers will accept those terms. They are similar to PPOs in that you do not need to choose a primary doctor (PCP) and you do not need referrals to see specialists. Prescriptions may or may not be covered on a PFFS plan, however, this is the only type of Medicare Advantage plan that you can add a Part D prescription drug plan to if your plan does not cover medications.
For the most part, PFFS plans are more prevalent in rural communities where there are no providers who are generally part of insurance plan networks. If you are in a market where there is PFFS along with HMO and PPO plans, you should compare the plans well as PFFS may have higher out-of-pocket costs because of the nature of the plan.
The agents of Health Plans of Texas can help you review your situation to see if a PFFS is a good fit for you.
Contact us today to learn more about Medicare Advantage Plans.